Provider Demographics
NPI:1235162645
Name:NORCAL HEALTHCONNECT LLC
Entity Type:Organization
Organization Name:NORCAL HEALTHCONNECT LLC
Other - Org Name:PETALUMA VALLEY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:400 N. MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-778-1111
Mailing Address - Fax:707-525-5392
Practice Address - Street 1:400 N. MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-778-1111
Practice Address - Fax:707-778-9117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000001282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP40136GMedicaid
CAZZR00136GMedicaid
CALTM90008GAMedicaid
CA050136Medicare ID - Type Unspecified